Purpose:
Patient contracts are increasingly utilized in medical practice and have the potential to improve health outcomes in high-risk populations. However, as a relatively new tool, there has been limited research regarding the efficacy of patient contracts. Diabetic retinopathy (DR) is one of the leading causes of vision impairment in US adults and only 50-60% of adults with diabetes adhere to annual dilated fundus exam recommendations. This study aimed to evaluate the impact of patient contracts on follow-up adherence in patients with diabetes after a free, community-based eye screening.

Methods:
This prospective, randomized study implemented a non-invasive, non-mydriatic fundus camera in an urban, community-based pharmacy setting to screen for DR and other ocular diseases in patients with diabetes. Patients were randomized into a contract or non-contract group. Patients who signed a contract agreed to: 1) review their results with their primary care doctor, 2) follow-up with an ophthalmologist, and 3) inform research staff if/when they completed an eye appointment. All study participants and their primary care doctors were notified of their results via mail. Follow-up questionnaires were administered to all patients by telephone 3 months after the screening results were mailed.

Results:
Five hundred patients were screened and 113 (22.6%) had abnormal results. The majority of patients were African American (69.2%) and female (56.6%). The mean age was 55.2 years. Of the patients who had abnormal results, 34 (30.1%) adhered to follow-up recommendations. There was no significant difference in follow-up adherence between the contract (28.6%) and non-contract group (31.0%) (p=0.59). In addition, 70.4% of patients did not comply with at least one measure of the contract agreement.

Conclusions:
Contracts did not increase follow-up adherence to eye appointments in patients with diabetes. The majority of patients did not comply with their contract and follow-up adherence was low in both groups. Most research has yielded mixed results regarding the efficacy of contracts in improving health outcomes. Therefore, different types of contracts or other patient-centered tools should be evaluated in order to increase follow-up adherence in patients at high risk for DR.